A fee charged for each prescription of a drug, expressed as a percentage of that drug’s overall cost

A code that qualifies the coinsurance rate

A standard, nominal fee charged for each prescription of a drug

A code that qualifies the copay amount

Definition of the patients responsibility for a portion of the cost not covered by insurance for a particular pharmacy type within a drug tier

Generic or Branded Drugs included within the CoveragePlan’s formulary that could be prescribed as alternatives to the current FormularyDrug.

A description of the drug tiers used by the formulary and how those tiers implement copay and coinsurance amounts. Drug tiers do not have any inherent meaning that is consistent across all formularies. Rather, each tier is defined using this element.

A code that describes the coverage status of a drug in a health plan (e.g., preferred generic, specialty, etc.)

An email address for developers/public to report mistakes in the network and formulary data

The URL that goes directly to the formulary brochure for the specific standard plan or plan variation.

A Boolean indication of whether this drug tier supports a mail order pharmacy option

The URL that goes directly to the plan brochure for the specific standard plan or plan variation

Array of Networks within a plan.

A code that describes the network (in/out) status of a pharmacy, the duration of supply, and whether this is a mail order pharmacy.

Unique, 14-character, HIOS-generated Plan ID number. (Plan IDs must be unique, even across different markets.)

Type of Plan ID. For all Marketplace plans this should be: HIOS-PLAN-ID

A Boolean indication of whether the coverage plan imposes a prior authorization requirement on this drug.

A Boolean indication of whether the coverage plan imposes a quantity limit on this drug.

A Boolean indication of whether the coverage plan imposes a step therapy limit on this drug.

The URL that goes directly to the formulary brochure for the specific standard plan or plan variation.